The Kidney in Plasma Cell Dyscrasias
Contributions to Nephrology
Claudio Ronco Vicenza
The Kidney in Plasma
Basel · Freiburg · Paris · London · New York ·
Bangalore · Bangkok · Singapore · Tokyo · Sydney
Guillermo A. Herrera
St. Louis, Mo.
61 figures, 29 in color and 13 tables, 2007
Saint Louis University School of Medicine
Department of Pathology
1402 South Grand Blvd.
St. Louis, MO 63104 (USA)
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Library of Congress Cataloging-in-Publication Data
The kidney in plasma cell dyscrasias / volume editor, Guillermo A.
p. ; cm. – (Contributions to nephrology ; v. 153)
Includes bibliographical references and indexes.
ISBN-13: 978-3-8055-8178-3 (hard cover : alk. paper)
ISBN-10: 3-8055-8178-5 (hard cover : alk. paper)
1. Plasma cell diseases–Complications.
–Immunological aspects. 3. Amyloidosis–Complications.
I. Herrera, Guillermo A., MD.
globulin Light Chains. W1 CO778UN v.153 2007 / WJ 300
2. Paraproteinemias.3. Immuno-
Contributions to Nephrology
(Founded 1975 by Geoffrey M. Berlyne)
1 The Kidney in Plasma Cell Dyscrasias: A Current View
and a Look at the Future
Herrera, G.A. (Saint Louis, Mo.)
5 A History of the Kidney in Plasma Cell Disorders
Steensma, D.P.; Kyle, R.A. (Rochester, Minn.)
25 Pathologic Studies Useful for the Diagnosis and
Monitoring of Plasma Cell Dyscrasias
Veillon, D.M.; Cotelingam, J.D. (Shreveport, La.)
44 Serum Free Light Chains in the Diagnosis and
Monitoring of Patients with Plasma Cell Dyscrasias
Mayo, M.M.; Schaef Johns, G. (St. Louis, Mo.)
66 Mechanisms of Renal Damage in Plasma Cell Dyscrasias:
Merlini, G. (Pavia); Pozzi, C. (Lecco)
87 Proximal Tubular Injury in Myeloma
Batuman, V. (New Orleans, La.)
105 Paraproteinemic Renal Diseases that Involve the Tubulo-Interstitium
Herrera, G.A. (St. Louis, Mo.); Sanders, P.W. (Birmingham, Ala.)
116 The Mesangium as a Target for Glomerulopathic Light and Heavy Chains:
Pathogenic Considerations in Light and Heavy Chain-Mediated
Keeling, J.; Herrera, G.A. (St. Louis, Mo.)
135 Immunoglobulin Light and Heavy Chain Amyloidosis AL/AH:Renal
Pathology and Differential Diagnosis
Picken, M.M. (Maywood, Ill.)
156 Diversity and Diversification of Light Chains in Myeloma:
The Specter of Amyloidogenesis by Proxy
Gu, M.; Wilton, R.; Stevens, F.J. (Argonne, Ill.)
182 High-Dose Therapy in Patients with Plasma Cell Dyscrasias
and Renal Dysfunction
Pineda-Roman, M.; Tricot, G. (Little Rock, Ark.)
195 Current and Emerging Views and Treatments of Systemic
Immunoglobulin Light-Chain (AL) Amyloidosis
Comenzo, R.L. (New York, N.Y.)
211 Author Index
212 Subject Index
Herrera GA (ed): The Kidney in Plasma Cell Dyscrasias.
Contrib Nephrol. Basel, Karger, 2007, vol 153, pp 1–4
The Kidney in Plasma Cell
Dyscrasias: A Current View and
a Look at the Future
Guillermo A. Herrera
Department of Pathology, Saint Louis University School of Medicine,
Saint Louis, Mo., USA
A book with an identical title to the one now compiled: The kidney in
plasma cell dyscrasias was edited by Minetti, D’Amico and Ponticelli and pub-
lished in 1988 by Kluwer Academic Publishers . The book is a collection of
manuscripts compiling the presentations at a meeting by the same name held in
Milan in 1987 in which the leading researchers and clinicians in the field par-
ticipated. The book provides a rather comprehensive state of the art of the sub-
ject summarizing knowledge available two decades ago.
In the last chapter of this book titled Conclusions, Dr. J.S. Cameron makes
a number of interesting comments worth reflecting on 18 years later. When he
discusses mechanisms of renal damage, there is ample information provided
regarding proximal and distal tubular nephrotoxicity. Mechanisms involved in
these are summarized and; although the refined molecular understanding of the
pathological processes that we command today did not exist then, the overall
conceptual mechanistic views as to how damage occurs is quite similar to our
current perception. What is remarkable is that he clearly stated that there was no
idea as to how glomerular damage occurred in these monoclonal light chain-
related disorders. The readers will observe as they peruse and read this book, that
our understanding of how glomerular damage occurs has remarkably improved
in the last two decades. The present book devotes several chapters to various
glomerulopathies associated with deposition of immunoglobulin light and heavy
chains, including those associated with amyloidosis, highlighting sequential
events that take place and delineating crucial steps and key molecules involved
amenable to modulation or control. Another notable difference is that there has
been significant improvement in the therapy of these conditions using innovative
means. Likewise, the increased sophistication in therapy is highlighted in the
book chapters dealing with this subject. Although the emphasis in these chapters
addressing the therapy is placed on the management of cases with renal involve-
ment, a distinct focus in addressing the diseases as a whole as they impact the
patients’general health and prognosis has been maintained in the discussions.
The chapters in this book address the entire pathological spectrum of mono-
clonal light chain-related renal diseases and provide a comprehensive up to date
compendium of information that should be valuable to a variety of disciplines.
Drs. Steeusma and Kyle provide a historical account of how throughout the years
we have increased our understanding of these diseases highlighting the key devel-
opments that have taken place in the field. This chapter provides a wonderful intro-
duction to the entire book and clearly provides a historical account dealing with the
sequence of events that have taken place throughout the years culminating in our
current knowledge. Cotelingam and Veillon address the diagnosis of plasma cell
dyscrasias in the anatomic and pathology laboratories. Significant advances in this
area now permit a rather sophisticated and accurate evaluation of paraproteins in
the serum and urine, not only for diagnostic purposes, but also to follow these
patients and to assess pertinent prognostic and therapeutic issues. Mayo and Johns
address in their chapter the use of serum free light chains in the diagnosis and
monitoring of patients with plasma cell dyscrasias. They summarize the current
knowledge regarding the applications of this relatively new test in clinical practice.
Merlini summarizes in a succinct yet lucid fashion the main mechanisms involved
in the pathogenesis of the various renal manifestations of plasma cell dyscrasias.
The type of renal damage in these conditions is quite broad and heterogeneous.
Understanding mechanisms involved not only clarifies how it happens mechanisti-
cally, but it also delineates basic science considerations that serve to explain why
renal alterations can be so diverse, a good example of how research can translate
from the bench to the bedside to enhance patients’management. Dr. Batuman has
spent a significant amount of this career in deciphering how proximal tubular dam-
age occurs in some patients with monoclonal light chain-associated diseases. His
chapter provides a translational approach to the understanding of this subject.
Likewise, Dr. Sanders has conducted sophisticated and elegant research in the area
of distal nephron obstruction associated with myeloma. In his chapter, he outlines
how crucial is for particular structurally abnormal light chains to interact with
Tamm-Horsfall protein as they engage in creating distal tubular casts. My labora-
tory has been engaged in the study of the pathogenesis of glomerular damage in
monoclonal light chain related renal diseases for the last 15 years. Dr. Keeling has
been involved in defining how crucial are interactions between some light chains
and mesangial cells resulting in the pathological alterations that we observe in
these conditions and how functional alterations of mesangial cells inevitably affect
the surrounding mesangial matrix. Dr. Picken’s chapter provides an in-depth
Kidney in Plasma Cell Dyscrasias3
excursion into light and heavy chain associated amyloidosis with emphasis on
diagnostic aspects and pathogenesis. Dr. Steven’s group has conducted seminal
research dealing with the characterization of abnormal light chains and the impact
of this biochemical characterization on the pathogenicity (including nephrotoxic-
ity) of these monoclonal light chains. They provide us with a detailed summary of
their research and how this information fits into the understanding of renal damage
in plasma cell dyscrasias. Finally, the chapters by Roman-Pineda and Tricot, as
well as Comenzo, leaders in the clinical management of these patients, detail cur-
rent therapeutic protocols used, particularly in those patients with renal involve-
ment. These two chapters clearly show the great advances that have taken place in
the last 20 years in the treatment of these conditions.
It should be noted that heavy chain-associated renal diseases were not
known until the 1990s, so it is in this book (not in the previously published) that
conditions such as heavy chain deposition disease and heavy chain-related amy-
loidosis are discussed as specific entities. While our understanding of the
pathogenesis of heavy chain-associated disorders is still primitive, we are
becoming proficient at diagnosing them accurately.
Much has been done in the biochemical characterization of pathogenic light
chains. This work has clearly shown that these pathological light chains exhibit
peculiar amino acid alterations in the variable portion of the light chain molecule.
While those alterations in some instances are quite characteristic (i.e. the amino
acid substitution in position 30 of the variable portion of the ? 1 light chain mole-
cule on acquired renal Fanconi’s syndrome), in other monoclonal light chains-asso-
ciated conditions the structural changes noted are significantly more variable and
complex. The abnormality in the light chains associated with the Fanconi’s syn-
drome has been shown to render the altered light chain resistant to catabolism, thus
crystalline structures are formed in the cytoplasm of the proximal tubular cells.
Animal models of these diseases have not been easy to create. Recent devel-
opments have resulted in the creation of an animal model of acquired renal
Fanconi’s syndrome . This exciting discovery should lead the way for other
models of these diseases to be developed. Animal models are most useful to test
new therapeutic interventions and provide a solid platform to test the clinical
importance what has been observed in vitro. Undoubtedly, animal models bridge
the gap between experimental work and reality. As demonstrated by Sirac et al.
in their seminal paper, design of therapeutic interventions leading to reversibility
of these disorders is possible once their pathogenesis is clearly elucidated [2, 3].
In the era of molecular understanding of diseases, monoclonal light chain-
related renal disorders have not been left behind. These diseases are understood
with much better details at the present time. While advances in molecular-
targeted pharmacotherapy for renal disorders have taken place relatively slowly,
it is anticipated that new therapeutic interventions will be designed at a much
faster pace in the near future. Obviously designing such therapeutic avenues is
only possible because we have acquired a sound and comprehensive molecular
understanding of the pathogenesis of these disorders.
1 Cameron JS: Conclusions; in Minetti L, D’Amico G, Ponticelli C (eds): The Kidney in Plasma
Cell Dyscrasias. Dordrecht, The Netherlands, Kluwer Academic Publishers, 1988, pp 291–299.
Sirac C, Bridoux F, Carrion C, et al: Role of the monoclonal k chain V domain and reversibility of
renal damage in a transgenic model of acquired Fanconi syndrome. Blood 2006;108:536–543.
Herrera GA: Animal models: a pot of gold. Blood 2006;108:414.
Prof. Guillermo A. Herrera, MD
Saint Louis University School of Medicine, Department of Pathology
1402 South Grand Blvd.
St. Louis, MO 63104 (USA)
Tel. ?1 314 577 8475, Fax ?1 314 268 5478, E-Mail Guillermo.Herrera@tenethealth.com
Herrera GA (ed): The Kidney in Plasma Cell Dyscrasias.
Contrib Nephrol. Basel, Karger, 2007, vol 153, pp 5–24
A History of the Kidney in Plasma
David P. Steensma, Robert A. Kyle
Mayo Clinic, Rochester, Minn., USA
Background: The kidneys are commonly injured in plasma cell dyscrasias. Methods:
We reviewed the pertinent medical literature related to the historical development of clinical
nephrology and diagnostic renal pathology; early case reports of patients with plasma cell dis-
orders; and historical descriptions of multiple myeloma, amyloidosis, and the renal disorders
that are associated with these conditions. Results: Medieval uroscopists recognized protein-
uria, and in 1827 Richard Bright first linked proteinuria to both dropsy (edema) and the
autopsy finding of chronically diseased, scarred kidneys. In the 1840s, Henry Bence Jones
and William Macintyre described a peculiar form of proteinuria in a middle-aged English gro-
cer with fragile, tumor-riddled bones; this proteinuria became known as ‘Bence Jones type’. It
was initially believed that Bence Jones proteins were harmless to the kidney, but after 1899
(when myeloma cast nephropathy was recognized), investigators observed numerous renal
injury patterns associated with plasma cell dyscrasias. Gross observations of ‘waxy degenera-
tion’or ‘lardaceous change’in organs including the kidney yielded to the misnomer ‘amyloid’
in 1854, when iodine staining suggested to Rudolf Virchow that the strange material present in
these conditions was a form of starch or cellulose. During the 20th century, biochemists and
physicians carefully studied patients with myeloma, in order to better define the nature and
structure of normal and pathological immunoglobulins. Conclusion: Historical understand-
ing of the kidney in plasma cell disorders reflects developments in understanding of the
anatomy and physiology of the kidneys in health and in disease.
Copyright © 2007 S. Karger AG, Basel
General Considerations:Evolution of Clinical
Nephrology and Diagnostic Renal Pathology
Physicians have been interested in the role of the kidney in human disease
since antiquity, yet clinical nephrology and diagnostic renal pathology are
relatively new biomedical disciplines, formalized only in the second half of the
20th century [1, 2]. In the early 19th century, abnormalities in the gross appear-
ance of the urine and the kidney were first reported in association with the clin-
ical conditions now grouped together as plasma cell disorders. In contrast,
microscopic descriptions of specific renal disease patterns in the monoclonal
gammopathies only began with the recognition of myeloma cast nephropathy in
1899, and most reports belong to the late 20th century [3, 4]. Advances in our
collective understanding of the various renal injuries complicating plasma cell
dyscrasias are best understood within the context of more general insights into
the anatomy and physiology of the kidney, both in health and disease.
Many ancient texts contain observations of the kidneys and theories about
their afflictions, but the first major treatise devoted solely to diseases of the kid-
neys and urinary tract was probably that of Rufus of Ephesus . Rufus was
a leading Greek physician who flourished during the reign of the Roman
Emperor Trajan (98–117 AD) . Later writers referenced Rufus extensively,
including Claudius Galen (129–199 AD), and Rufus was especially influential
among the medieval Islamic physicians, who translated more than 50 of his
works into Arabic . Rufus of Ephesus was appreciated for the richness of his
clinical descriptions, and some credit him with being the first to notice the
hardened, shrunken kidneys of what is now referred to as ‘end stage’renal dis-
ease. Little else is known of Rufus, and only fragments of his original works
have survived . In the centuries after Rufus, many major authorities
addressed urolithiasis and hematuria, but the kidneys themselves remained
mysterious and received relatively little attention.
Uroscopy, the practice of carefully examining the appearance of patients’
urine – known colloquially as ‘water gazing’ performed by ‘piss-prophets’
(fig. 1) – was advocated by many historical medical authorities, including both
Hippocrates (cf. 460–377 BCE) and Galen. In his famous Canon of Medicine,
the Persian physician and philosopher Avicenna (Ibn Sina; 980–1037 AD)
insisted that physicians should routinely examine their patients’urine. The prac-
tice of uroscopy reached its zenith during the time of French physician and
humanist Pierre Gilles de Corbeil (Aegidius Corboliensis; 1165–1223) (fig. 2),
whose influential treatise De urinis, de pulsibus, de virtutibus, et laudibus
compositorum medicamentorum includes observations on dozens of subtly dis-
tinct physical states of urine. Frequently, uroscopy substituted for a physical
examination, which many academic doctors in this era considered improper or
A History of the Kidney7
Medical practitioners in the Middle Ages practiced uroscopy so often that
the icon of the glass urine flask became identified with physicians as closely as
the image of the stethoscope would in the 20th century (fig. 1). Geoffrey
Chaucer’s physician-pilgrim – who esteemed Rufus of Ephesus as one of the
many authorities supporting his opinions – is depicted gazing at a urine flask in
the illuminated Ellesmere manuscript of the 14th-century Canterbury Tales, in
the rather unlikely position of practicing uroscopy while riding on horseback
(fig. 3). Chaucer’s Host praises the physician for his storytelling by blessing his
urine examinations and his flasks:
Fig. 1. A classic image of uroscopy: ‘The Physician’ by Gerrit Dou (1613–1675), a
Dutch painter who was a pupil of Rembrandt van Rijn. Dated 1653, oil on oak,
49.3 ? 37cm, Kunsthistorisches Museum, Vienna. In this case, the reddish color of the liq-
uid in the flask and the imagery suggest that the physician was performing a pregnancy test.
In the 17th century, urine was sometimes mixed with red wine for this purpose, a procedure
that altered the appearance of urine proteins observed in many pregnant women.
Fig. 2. A 1967 semipostal stamp from Belgium illustrating
Pierre Gilles de Corbeil (1140–1224), also known as Aegidius
Corboliensis, who distinguished more than 19 substances in
urine, separating them by consistency, sedimentation, quantity,
and quality. Author’s collection.
I pray to God so save thy gentil cors,
And eek thyne urynals and thy jurdones,
Thyn ypocras, and eek thy galiones,
And every boyste ful of thy letuarie,
God blesse hem, and oure lady Seinte Marie!
(Introduction to The Pardoner’s Tale, lines 304–308) 
Gross observation of urine has been practiced for millennia, but chemical
analysis of the urine was first systematized in the early 1800s. During this
period, the rise of ‘animal chemistry’ (i.e., what is now called clinical chemis-
try) in British, French and German hospitals facilitated detailed analyses of all
body excreta, especially the urine. Richard Bright (1789–1858), an energetic
and enormously popular physician at Guy’s Hospital in London, was not the
first to recognize albumin in the urine, but he did develop a simple test for pro-
teinuria in 1827: holding a small quantity of urine in a spoon over a candle .
Bright was the first to connect urine that curdled when treated in this way with
the clinical condition of dropsy (edema) and the autopsy finding of shriveled,
scarred kidneys (fig. 4). For more than a century after his work, all chronic kid-
ney diseases, especially progressive parenchymal renal disorders, were grouped
together and called ‘Bright’s disease’. Bright also clearly distinguished renal
edema from the forms of edema associated with heart and liver disease,
although he was not the first to do so . The same milieu of exhaustive chem-
ical analysis that Bright worked in also made possible the description of the
Bence Jones protein in the 1840s , the landmark event in the history of the
plasma cell dyscrasias (described in more detail below).
Marcello Malpighi (1628–1694) of Bologna, one of the founders of micro-
scopical anatomy and a contemporary of the Dutchman who invented the
A History of the Kidney9
microscope, Anton van Leeuwenhoek (1632–1723), was the first to describe
the renal glomeruli (‘Malpighian corpuscles’) in his text De renibus in 1666
[12–14]. Malpighi identified these structures by perfusing renal arteries with a
solution of India ink and alcohol. The eponym ‘Malpighi’is rarely used today to
describe glomeruli, because of potential confusion with the Malpighian corpus-
cles of the spleen (i.e., the while pulp of the spleen, lymphoid follicles).
Coincidentally, in both the kidney and the spleen, Malpighian corpuscles are
the preferential places for amyloid proteins to deposit.
Almost two centuries after Malpighi, William Bowman (1816–1892) in
London identified a small capsule surrounding the glomerulus (in 1841), a
structure which now carries his name [15, 16]. The delicate interface between
the glomerulus and Bowman’s capsule is frequently disrupted in plasma cell
dyscrasias. In 1862, another major portion of the renal filtration apparatus – the
U-shaped loop of the renal tubule – was noted by Friedrich Gustav Jacob Henle
(1809–1885), who worked at the University of Göttingen in Germany and bene-
fited from newly invented achromatic microscope lenses [17, 18]. Axel Key
(1832–1901), a Swede, is credited with discovery of mesangial cells in 1860 –
but Key is much better known for his diplomatic skills, which he used while
Fig. 3. Fourteenth-century version of point-of-care urinalysis: Geoffrey Chaucer’s
physician water-gazing. Detail from the Ellesmere Chaucer in the Huntington Library.
serving as the Rector of Karolinska Institute in Stockholm to persuade Alfred
Nobel and the executors of Nobel’s will to sponsor the Nobel prize in
Physiology or Medicine .
Despite these anatomical advances, theories of renal physiology remained
somewhat simplistic until the early 20th century, when a series of painstaking
animal and human experiments by many investigators – above all Homer Smith
(1895–1962) in New York – led to the present paradigm [20, 21]. The work of
Smith and his contemporaries revealed that the kidney is the essential organ for
maintaining physiological salt, water, and acid-base balance; these studies also
clarified the precise role of the kidney in excreting various metabolic by-products,
toxins, and other substances from the body. Even though the mechanisms of
these complex processes are now well understood, the fact that the kidney is
able to ensure homeostasis over such a wide range of diets and under the influ-
ence of diverse hormonal signals and vascular states still seems remarkable.
Fig. 4. A portrait of Richard Bright, who first linked dropsy (edema), proteinuria, and
kidney disease. From Thomas Joseph Pettigrew’s Medical Portrait Gallery. London, Fisher,
Son, & Co. 1840.
A History of the Kidney11
Detailed understanding of microscopic renal pathology awaited the advent
of surgical kidney biopsy, and later percutaneous needle biopsy. Surgical biopsy
in the modern sense only became possible after 1837, when Gabriel Gustav
Valentin (1810–1883) in Bern invented the first crude microtome . A tissue
fixative was also essential; mercuric chloride and later formaldehyde were
introduced in the mid-19th century for this purpose, and both still enjoy wide-
Clinical reports and autopsy data from the middle of the 19th century fre-
quently included rudimentary renal histology on unstained specimens. Later in
the 19th century, various tissue stains were introduced, allowing more detailed
microscopic studies . The decades after 1856, when aniline dyes first came
into use, saw the introduction of most of the stains that are still used by patho-
logists today, including the classic hematoxylin (derived from Central American
logwood trees) and eosin combination, which debuted in 1875 . With these
new tools, pathologists – principally those working in the influential German
universities – were able to describe a wide range of abnormal morphological
patterns, including several in the kidney. The 1914 renal pathology textbook of
Franz Volhard and Karl Fahr of Giessen, Germany  is widely considered to
be the culmination of the early surgical pathology era .
Despite this body of work, systematic observations of renal histopathology
during life remained uncommon until the mid-20th century, and most reported
pathological patterns represented end-stage disease. Surgical biopsies were
rarely undertaken in clinical practice, and until the 1940s there were few
attempts at percutaneous needle biopsy. Notable among the successful early
biopsies was that of Stockholm orthopedist Johann Henning Waldenström
(1877–1972) in 1928, during the evaluation of a patient with amyloidosis .
Waldenström was the father of Jan Gosta Waldenström (1906–1996) , who
described his eponymous macroglobulinemia in 1944 .
A new era in renal pathology arrived when Poul Iversen and Claus Brun in
Copenhagen developed a reproducible technique of percutaneous biopsy of the
kidney in early 1949, publishing their results (with an initial 50% success rate)
to global interest in 1951 . Biopsy technique was refined in 1954 by Robert
C. Muehrcke (1921–) and Robert M. Kark (1911–2002) in Chicago, who used
a style of needle (Vim-Silverman) that is still common today (fig. 5). Kark and
Muehrcke also obtained biopsies with patients in the prone position, resulting
in a much greater degree of success . Much later, ultrasound guidance of
the biopsy needle made this procedure even safer.
Evolution of Nephrology
The advent of hemodialysis as a ‘renal replacement therapy’ is chiefly the
legacy of Willem Kolff (1911–), a true medical pioneer who used scavenged
parts to build the first rudimentary dialysis machines in the Netherlands at the
end of the Second World War, working under extremely difficult conditions .
Percutaneous biopsy coupled with hemodialysis led directly to the development
of the medical specialty of clinical nephrology, since by the 1950s both a techni-
cally challenging treatment (dialysis) as well as a new specialized diagnostic
procedure (biopsy) were available. In 1965, the American College of Physicians
recognized the discipline of nephrology as a subspecialty of internal medicine
. The American Society of Nephrology was founded in 1966, and the nephrol-
ogy subspecialty board offered its first certifying examination in 1972 .
Electron microscopy was added to the armamentarium of renal patholo-
gists in the late 1950s , contemporary with immunofluorescence  and
silver staining of ultrathin tissue sections . Together, these valuable tools led
to more refined characterization of the diverse pathologies that had once been
grouped together simply as ‘Bright’s disease’, as well as recognition of several
specific patterns associated with plasma cell dyscrasias [3, 35].
Multiple Myeloma and the Kidney
The first clear recognition of a plasma cell disorder as a unique clinico-
pathological entity resulted from detailed observations of a single patient, the
English grocer Mr. Thomas McBean, from the time his initial symptoms in 1843
until his death at the age of 45 on January 1, 1846 [36, 37]. Dr. William Macintyre
(1791–1857), a Harley Street practitioner, examined a urine specimen from
Mr. McBean, who had complained to Macintyre that his body linen was stiffened
by his urine. Macintyre found no evidence of sugar in the urine, but observed a
strange precipitate . Dr. Thomas Watson, another leading physician in
London, saw the patient in consultation at Macintyre’s request. Watson sent the
following note with some urine samples to Henry Bence Jones (1813–1873)
(fig. 6) , then a 31-year-old physician with a growing reputation as a chemi-
cal pathologist, who was working at St. George’s Hospital at Hyde Park Corner:
Silverman renal biopsy needle
Fig. 5. Diagram of a Silverman nee-
dle for percutaneous renal biopsy.
A History of the Kidney13
Saturday, November 1, 1845
Dear Dr. Jones,
This tube contains urine of a very high specific gravity. When boiled, it becomes highly
opake. On the addition of nitric acid it effervesces, assumes a reddish hue, and becomes quite
clear, but as it cools, assumes the consistence and appearance which you see. Heat re-lique-
fies it. What is it? [11, 40].
Bence Jones corroborated Watson’s findings that the addition of nitric acid
produced a strange precipitate in the urine that was re-dissolved by heat, and
that this precipitate formed again upon cooling. He credited Macintyre with
first observing this peculiar property of the urine . An exhaustive series of
chemical analyses including evaporation, precipitation, filtration, and various
solubility tests suggested to Bence Jones that this substance was probably a new
form of protein, which he believed to be a ‘hydrated deutoxide of albumen’
. Ordinary albumin did not react with nitric acid the way this new substance
Fig. 6. A portrait of Henry Bence Jones in the late 19th century, several decades after
his description of what became known as Bence Jones protein.
did. While the substance was somewhat akin to ‘hydrated tritoxide of protein’
that had been reported in the ‘inflammatory crust of the blood’ by the Dutch
chemist Gerardus Mulder (1802–1880) in 1838 , Mulder’s substance con-
tained no sulfur or phosphorous, and did not precipitate with ‘ferro-prussiate of
Despite Mr. McBean’s heavy proteinuria, at autopsy his kidneys appeared
normal, both grossly and microscopically. Amyloidosis was well-recognized by
that time (as ‘lardaceous change’ – see more below), and thus it is unlikely that
Mr. McBean’s kidneys were involved by amyloidosis. Macintyre wrote that in this
case, the kidneys had ‘proved equal to the novel office assigned them’, and had
‘discharged the task without sustaining, on their part, the slightest danger’.
Mr. McBean was considered by his physicians to have suffered from an
unusual variant of ‘mollities and fragilitas ossium’, terms that were used in the
19th century to refer to any condition of bone fragility, including osteogenesis
imperfecta and various other congenital or acquired osteopenias. John Dalrymple
(1803–1852), surgeon to the Royal Ophthalmic Hospital in Moorfields, England,
recognized at autopsy that McBean’s peculiar form of mollities ossium was due
to replacement of bone by a ‘gelatin-form substance of a blood red color and
unctuous feel’. Dalrymple also noted that the disease had apparently begun
in the cancellous bone, and then grew and produced regularly-sized, round, dark
red projections that were visible through the periosteum. Microscopic examina-
tion revealed strange new cells; illustrations from his report are recognizable as
Some earlier cases of mollities ossium are also consistent with potential
multiple myeloma, notably that of 39-year-old Sarah Newbury, the second
patient described by Samuel Solly, a distinguished London surgeon, in a case
series published in 1844 . Mrs. Newbury suffered excruciating bone pain
with fractures in her thighs, clavicles, humerus, radius and ulna. Autopsy find-
ings revealed that the cancellous portion of her sternum had been replaced by a
red substance, which Macintyre reported to be similar to the red substance seen
in the bones of Mr. McBean .
In 1867, Herman Weber (1823–1918), a German physician working in
London (and the father of the more famous Frederick Parkes Weber, who gave
his name to many clinical conditions, including Sturge-Weber, Osler-Weber-
Rendu, and Klippel-Trenaunay-Weber syndromes), described a 40-year-old
man with mollities ossium and amyloidosis who had suffered severe sternal and
lumbar pain . This was the first time a connection was made between
myeloma and amyloidosis. In this case, the amyloid deposits were found in the
kidneys and spleen.
The term ‘multiple myeloma’ was introduced in 1873 by J. von Rustizky in
Kiev, of whom little is known other than that he had once worked in Friedrich von
A History of the Kidney15
Recklinghausen’s laboratory in Strasbourg. During an autopsy, von Rustizky noted
eight separate tumors of the bone marrow in the patient, which he called ‘multiple
myelomas’. The report did not comment on whether Bence Jones proteinuria
was found during life.
In 1889, Otto Kahler (1849–1893), an internist from Prague working in
Vienna, described the case of a 46-year-old physician named Dr. Loos, who
developed pain in his right upper thoracic area aggravated by taking a deep
breath, followed by intermittent but severe pains in multiple areas of the body
. Albuminuria was first noted in Dr. Loos in 1881, 2 years after the initial
bone pain and anemia. The patient lived for 8 years after his first symptoms.
Autopsy findings included large round cells in the ribs and thoracic vertebrae.
Kahler recognized that the urinary protein excreted by Dr. Loos had the same
characteristics as that described by Bence Jones.
The first recognized case of multiple myeloma in the United States fol-
lowed shortly thereafter, reported in 1894 by James Bryan Herrick (1861–1954)
and Ludvig Hektoen at Rush Medical College in Chicago . Remarkably,
Herrick is also credited with the first description of sickle cell anemia, as well
as being the first to link angina with acute coronary syndromes [48, 49].
The nature and origin of the protein described by Bence Jones were com-
pletely mysterious until the middle of the 20th century. Proteinuria had been
recognized centuries before Bright and Bence Jones arrived on the scene, but
had long been thought to be identical with albuminuria [50, 51]. For instance,
Frederick Dekkers (1648–1720) in Leiden noted in 1694 that the urine of con-
sumptives became milky when placed over heat . However, it is not clear
whether Dekkers was truly describing albuminuria, or whether he was just
reflecting contemporary ideas of transformation of food in the stomach, fol-
lowed by further changes in the liver and then the kidneys – theories popular-
ized by the brilliant but eccentric alchemist Theophrastus Bombastus von
Hohenheim (Paracelsus) (1493–1541) in a 1527 essay . Domenico Cotugno
(1736–1822) of Bari, Italy – physician to the King of the Two Sicilies – in 1765
described a case of what is quite clearly nephrotic syndrome following a quo-
tidian fever, probably malaria, which was treated with quinine . Cotugno
refers to ‘urine, which is well known not to be coaguable’, and goes on to
describe the case of an edematous soldier whose urine, when exposed to fire,
turned into ‘a white mass, like egg albumin’ – the same observation exploited
by Bright 60 years later  William Cruickshank (? – approximately 1811), a
Scotsman who was an ordinance chemist working at the Woolwich Arsenal in
southeast London, noted that ‘in some diseases; however, particularly general
dropsy or anasarca, nitrous acid...produces a milkiness and in some cases a
coagulation similar to...the serum of the blood...in morbid states of the urine,
is detected...even by heat’. Three decades before Bright, Cruickshank had
noted that in the forms of dropsy associated with diseases of the liver or heart,
the urine did not demonstrate this feature . The clinical specimens were
provided to Cruickshank by the Surgeon General of the Royal Artillery, John
Rollo; the two also collaborated on the discovery of the element strontium .
Although initially myeloma proteins were felt to be harmless to the kidney,
it was soon apparent that this sanguine view was false. In 1909, Alfred von
Decastello (1872–?) in Vienna described an association between myeloma and
tubular plugging by an amorphous substance. This syndrome became known as
cast nephropathy, or ‘myeloma kidney’ . (Decastello, a colleague of Karl
Landsteiner, also described the AB blood group). By the early 1920s, most
medical experts accepted the concept that Bence Jones proteins could be
nephrotoxic [35, 57], but the origin of the protein was still unclear. In 1899,
A. Ellinger in Germany suggested that there might be an abnormal protein in
the blood in patients with myeloma that was similar to the Bence Jones protein,
but the evidence he provided was not conclusive . A Bence Jones-like protein
was more convincingly detected in the blood in 1929 . Arne Tiselius
(1902–1971) in Uppsala, Sweden, a 1948 Nobel Laureate in Chemistry,
reported an improved method of serum electrophoresis in 1937, which allowed
separation of serum globulins into three components: alpha, beta, and gamma
. In 1939, Tiselius isolated antibody activity in the gamma fraction ,
while Lewis Longsworth (1904–1981) and his colleagues at the Rockefeller
Institute used Tiselius’ electrophoretic techniques and first noted the classic
myeloma ‘M-spike’in that same year .
Beginning in the 1930s, there was considerable debate between two schools
of thought on the origin of Bence Jones protein. The first theory, championed by
Adolf Magnus-Levy (1865–1955) in Berlin , held that proteinaceous materi-
als found in the distal nephron were simply the result of overproduction of nor-
mal serum proteins by the bone marrow. The contrary view was held by Maxwell
Wintrobe (1901–1986) and M.V . Buell at Johns Hopkins in Baltimore. In a
description of the phenomenon of cryoprecipitation in 1933, Wintrobe and Buell
championed the belief that the pathologic proteins in plasma cell disorders were
distinct from all normal serum components . The clinical syndrome of cryo-
globulinemia was named by A.B. Lerner and C.J. Watson in 1947 .
In the early 1950s, protein chemist Frank W. Putnam at the University of
Chicago performed a series of experiments in myeloma patients with radioiso-
topes, which helped clarify the origin of Bence Jones proteins. Putnam first
showed that the Bence Jones proteins from 18 different patients with myeloma
were all unique, though they clustered into two antigenic groups. In 1955,
Putnam and Hardy  showed that Bence Jones proteins derived directly from
the body’s metabolic pool of nitrogen, rather than being a breakdown product of
some sort of plasma precursor. The following year, biochemist Leonhard
A History of the Kidney17
Korngold and his assistant Rosa Lipari at Sloan Kettering and Cornell in New
York City distinguished two different classes of Bence Jones proteins, and they
showed a relationship between these and the serum proteins of multiple
myeloma as well as normal globulins . The immunoglobulin light chains
are now called kappa and lambda, after Korngold and Lipari’s surnames.
Stanhope Bayne-Jones (1888–1970) and D.W. Wilson at Johns Hopkins had
recognized two or three distinct groups of Bence Jones proteins as early as
1922, but had not shown their relationship to serum proteins .
In 1962, Gerald M. Edelman (1929–) and Joseph A. Gally at the
Rockefeller Institute in New York conclusively demonstrated that light chains
prepared from serum immunoglobulin, myeloma proteins, and Bence Jones
proteins from the same patient’s urine were identical in all respects: in molecu-
lar weight, amino acid sequence, chromatographic appearance, and thermal
solubility . The immunoglobulin light chains precipitated at temperatures
between 40?C and 60?C, and dissolved upon boiling, just as Bence Jones had
described more than a century earlier. Edelman shared the 1972 Nobel Prize for
his ‘discoveries concerning the chemical structure of antibodies’.
By the early 1960s, the harmful nature of myeloma proteins to the proximal
tubules of the kidney was well established, and investigators began to recognize
additional injury patterns beyond cast nephropathy. The first description of an
association between myeloma and acquired Fanconi syndrome (i.e., defective
proximal tubular reabsorption) came in 1963 . Tubular cast formation in
myeloma was correlated with the degree of renal failure in the late 1970s. Non-
amyloid glomerulopathies were also first described in this era. In 1957, Sidney
Kobernick and J.H. Whiteside at McGill University in Montreal first documented
glomerular abnormalities in myeloma patients, including patterns of nodular
glomerulosclerosis that resembled lesions seen in diabetics . Other groups
quickly confirmed this observation . R.E. Randall  at the University of
St. Andrews in Scotland reported light chain deposition disease in 1976. Non-
amyloidogenic light chains in myeloma are sometimes called ‘Randall-type’. A
much rarer condition, heavy chain deposition disease, was recognized in the early
1990s by Pierre Aucouturier and his colleagues in Poitiers, France . In 1984,
myeloma was linked to cases of rapidly progressive (‘crescentic’) glomerulopathy
, and Mayo Clinic investigators reported a case series of monoclonal gam-
mopathy-associated focal and segmental glomerulosclerosis in 2005 .
The Kidney in Systemic Amyloidosis
The word ‘amyloid’ (starch-like) was coined in the late 1830s by the
German botanist Matthias Schleiden (1804–1881) of the University of Jena, in
his seminal formulation of the cellular theory of life , a theory that was
extended to animal tissues by his colleague and compatriot Theodore Schwann
(1810–1882). The word amyloid derives from the Latin word amylum, and is a
transliteration of the Greek amyl-on, a term that meant ‘not ground at the mill’
and that referred to fine grains, especially starch.
Amidon and amydon were used as cooking terms for starch in the Medieval
period. Starch – a complex carbohydrate that is insoluble in water – is a combin-
ation of two polymeric carbohydrates: amylose and amylopectin. Starch is dis-
tinct from cellulose, a word once used as a synonym for ‘cellular’in the sense of
compartmentalized, but which after the 1830s saw more specific use to refer to
a long-chain polymer of beta glucose that forms the primary structural compo-
nent of plants, and is indigestible by humans. Cellulose was first noted to be
common in plant cell walls in 1838 .
Antoine Portal (1742–1832), physician to Charles X and Louis XVIII of
France, was probably the first to describe a substance similar to lard in the liver
of an elderly woman in 1787, and later in the liver of an 8-year-old boy; Portal
also noted kidneys ‘three times fattier than normal’[77, 78]. Because the mater-
ial from lardaceous liver hardened like albumin when exposed to heat, Portal
thought that his patients had some sort of albuminous obstruction. In 1842, the
Bohemian physician Carl Freiherr von Rokitansky (1804–1882), working at the
University of Vienna, described in his widely-read pathological handbook 
the condition of lardaceous liver enlargement as a result of infiltration by an
albuminous, gelatinous, grayish material. He noted that there was an associa-
tion between the presence of this material and scrofula, rickets, syphilis, or mer-
cury use. Rokitansky also stated that the finding of lardaceous liver was, ‘nicht
gar zu selten die Bright’sche Nierenkrankenheit und deiser verwandte Züstande
der Nieren Combinirt’ (page 312, volume 3 of the Handbuch) – i.e., that not
uncommonly, fatty degeneration of the liver was associated with Bright’s dis-
ease of the kidney or various other renal conditions.
In 1854, Rudolf Virchow (1821–1902) in Berlin noted that the corpora
amylacea – tiny degenerative bodies in the nervous system that had been
described by Czech anatomist Jan Evangelista Purkyne ¤ (1787–1869) – stained a
peculiar violet-brown color with iodine and dilute sulfuric acid [80, 81].
Virchow used the term ‘amyloid’ for the material that comprised these bodies,
because he was convinced that these were identical or at least very similar to
cellulose, although the staining pattern was a slightly different color than that
seen with starch . Virchow much preferred ‘amyloid’to the commonly used
terms ‘lardaceous’or ‘waxy’, because the staining pattern suggested to him that
the material was carbohydrate and not fat; he often commented that those who
used the term ‘lardaceous’ were not good connoisseurs of bacon. The French
school continued to prefer the term ‘lardaceous’ as described by Rokitansky,
A History of the Kidney 19
whereas English and Scottish physicians used the term ‘waxy’, in part because
noted Edinburgh physician John Abercrombie (1780–1844) in 1828 described
the liver in these conditions as a uniform dull yellow that closely resembled the
color of impure beeswax [83, 84].
Virchow’s ideas were influential, and he held tenaciously to his original
beliefs about cellulose despite growing contradictory evidence, probably
because he was convinced he had found a fundamental and previously unrec-
ognized connection between animals and plants, unifying these two great king-
doms of life . It is a consequence of Virchow’s considerable prestige that the
somewhat inaccurate term ‘amyloid’ persists, even though it was subsequently
demonstrated even in his lifetime that the degenerative substance was not a typ-
ical carbohydrate, nor was it likely to be a fat. For instance, German orga-
nic chemists Friedrich August Kekulé (1829–1896) and Nikolaus Friedreich
(1825–1882) noted that the ‘lardaceous’material was actually nitrogenous .
(Kekulé later became famous for his discovery of the cyclic nature of the ben-
zene molecule, an idea that he claimed came to him after a dream in which a
snake was seen eating its own tail) George Budd (1808–1882) of King’s College
in London performed a similar analysis, using a sample from a patient of his
brother William in Bristol – a patient with an enormous, pale, lardaceous liver
that turned out to have 3 times as much albumin as fat . Budd also
recognized similar changes in the kidney [84, 86]. In 1854, W.T. Gairdner of
London came to similar conclusions about the lack of genuine fat in lardaceous
Primary amyloidosis was probably first reported in 1856, when Samuel
Wilks (1824–1911), then at Guy’s Hospital in London , described a 52-year-
old man with lardaceous viscera, including the kidney, in whom the changes
were unrelated to known associated conditions such as syphilis, osteomyelitis,
other osseous disease, or tuberculosis. All previously described patients had sec-
ondary amyloidosis consequent to chronic inflammation. Wilks’ patient had
albuminuria as well as dropsy. Wilks also reported involvement of the adrenal
glands with lardaceous disease in 1860, in a patient who had syphilis and larda-
ceous changes that also affected the liver, kidneys, and spleen . In 1869,
William Howship Dickinson (1832–1913) in London described a case of larda-
ceous disease involving only the kidney, which was attributed to an ovarian
abscess [90, 91].
During this era, the ‘sago spleen’was first noted. Sago is the pith found inside
of the stems of some cycad plants of the genesis Cycas, the most notable being
Cycas revoluta. Segu is a Malay word; Europeans first encountered this substance
in the 1550s during explorations of New Guinea and the Moluccas in the South
Pacific. Today, sago continues to be used in steamed puddings and as a thickener
for other dishes. It has similar consistency to tapioca, the pith of the cassava plant.
The iodine-sulfuric acid staining method was the initial test for amyloid,
most notably used (after Virchow) by Johann Heinrich Meckel von Hemsbach
(1822–1856) , whom Virchow succeeded as prosector at the Charité
Hospital in Berlin following Meckel’s untimely death from tuberculosis.
Meckel annoyed Virchow by holding the view that the lardaceous deposits con-
sisted of ‘cholesterine’ (an older term for cholesterol), and that they were not
the result of cellulose degeneration.
Metachromatic stains for amyloidosis, an improvement over less specific
iodine techniques, were introduced in 1875 [82, 93]. The aniline dyes methyl vio-
let and crystal violet produce characteristic color changes in amyloid tissues .
Congo red, another aniline compound (an azo dye), was first introduced in the
1880s as a textile dye . Hans-Hermann Bennhold (1893–1976) in Tübingen
noted its relative specificity for amyloid in 1922, and intravenous Congo red infu-
sions became an early diagnostic test for amyloidosis . In 1927, psychiatrist
Paul Divry (1889–1967) and biochemist Marcel Florkin (1900–1979) in Liége,
Belgium, recognized the specific apple green birefringence of amyloid fibrils
when stained with Congo red and viewed under polarized light . The fibril-
lary structure of both primary and secondary amyloid proteins were reported in
1959 by Alan S. Cohen and Evan Calkins (both fl. 2006) in Boston, and resulted
from detailed electron microscopic observations [98, 99].
As with most conditions, it is possible to find early case reports potentially
consistent with amyloidosis . For instance, in 1639, the Belgian physician
Nicolaus Fontanus (Fonteyn; Nicolao Fontano) in his monograph Responsionum
& Curationum Medicinalium Liber Unus described a patient with ascites, jaun-
dice, epistaxis with an abscess in the liver and a large spleen filled with strange
white stones . There is no mention of kidney anomalies. In 1654, Thomas
Bartholin (1616–1680) of Copenhagen, the discoverer of the lymphatic system,
described the autopsy of a woman whose spleen resembled indurated flesh in
his Historiarum Anatomicarum Rariorum Centuria . Bartholin reported
that her spleen was so hard that it could scarcely be cut with a knife, and inci-
sion of the spleen produced a sound like that of cutting spongy timbers.
However, it is not possible to be certain about either of these patients, because
of the brief description and lack of special stains at the time.
In 1929, the Soviet physician Mikhail Innokentevich Arinkin (1876–1949)
in Leningrad reported aspiration of sternal bone marrow in life. An earlier
report of marrow aspiration in 1908 by Giovanni Ghedini in Italy had gone
largely unheeded, in part because Ghedini chose to aspirate the tibia, which was
less representative of the overall marrow architecture than marrow from the
axial skeleton [102–104]. Bone marrow examination subsequently became rou-
tine in the evaluation of blood disorders, and it is now common to stain bone
marrow with Bennhold’s Congo red to determine the presence of amyloid
A History of the Kidney 21
within the marrow, including in the blood vessels. Even though the diagnosis of
amyloidosis can usually be made by examining other tissues, renal biopsy is
still often necessary to determine the specific pathological pattern in the kidney.
Injury to the kidney is one of the cardinal features of plasma cell disorders,
and an unusual case of proteinuria led to the first clear description of one of
these hematological malignancies in the 1840s. Myeloma cast nephropathy and
amyloid deposition are the most common renal damage patterns, but several
other types of renal dysfunction exist. The history of evolving understanding of
this group of conditions illustrates the importance of careful bedside observa-
tion and clinical reasoning, supported by developments in basic sciences.
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David P. Steensma, MD
Associate Professor of Medicine and Oncology
Senior Associate Consultant
Division of Hematology, Department of Medicine, Mayo Clinic
200 First Street SW
Rochester, MN 55905 (USA)
Tel. ?1 507 284 2479, Fax ?1 507 266 4972, E-Mail email@example.com
Herrera GA (ed): The Kidney in Plasma Cell Dyscrasias.
Contrib Nephrol. Basel, Karger, 2007, vol 153, pp 25–43
Pathologic Studies Useful for the
Diagnosis and Monitoring of Plasma
Diana M. Veillon, James D. Cotelingam
Department of Pathology, Louisiana State University, Health Sciences Center,
Shreveport, La., USA
The pathologic diagnosis of multiple myeloma and other plasma cell dyscrasias includes
histopathologic examination of a bone marrow aspirate and biopsy and clinical laboratory
tests to assess end organ damage and other prognostic information. Plasma cell dyscrasias are
characteristically classified and staged based on the results of these pathologic studies in con-
junction with other clinical and radiologic parameters. New staging systems such as the
International Staging System (ISS) use readily available laboratory tests to stratify prognostic
subgroups. The continued introduction of new laboratory assays will help improve our under-
standing of plasma cell dyscrasias and the therapeutic management of these patients.
Copyright © 2007 S. Karger AG, Basel
The pathologic diagnosis of multiple myeloma and other plasma cell
dyscrasias includes a bone marrow aspirate and biopsy to assess the percentage
of plasma cells and clinical laboratory tests to assess end organ damage and
other prognostic information. Plasma cell dyscrasias result from a clonal expan-
sion of neoplastic plasma cells that usually secrete a monoclonal protein or
M-component. These diseases are characteristically classified and staged based
on the results of pathologic studies and other clinical and radiologic parameters.
The World Health Organization classification of ‘plasma cell neoplasms’ is
shown in table 1 .
The diagnosis of multiple myeloma requires evaluation of a Wright-
Giemsa stained bone marrow aspirate and a hematoxylin and eosin stained core
biopsy section. Current diagnostic criteria, shown in table 2, include a mini-
mum of one major and one minor criteria . Alternatively, three minor criteria
which must include marrow plasmacytosis and presence of a M-component are
sufficient for a diagnosis of multiple myeloma. On bone marrow aspirate (fig. 1)
and biopsy (fig. 2), an increase in plasma cells is usually evident. The morphol-
ogy of these cells is variable. The neoplastic cells may resemble benign mature
Table 1. WHO classification of plasma cell neoplasms 
Plasma cell myeloma
• Indolent myeloma
• Smoldering myeloma
• Non-secretory myeloma
• Plasma cell leukemia
Osteosclerotic Myeloma (POEMS syndrome)
Immunoglobulin deposition diseases
• Primary amyloidosis
• Systemic light and heavy chain deposition diseases
Heavy chain diseases (HCD)
• Solitary plasmacytoma of bone
• Extramedullary plasmacytoma
Table 2. Diagnostic criteria for multiple myeloma
• Marrow plasmacytosis ?30%
• Serum IgG ?3.5g/dl or IgA ?2g/dl
• Urine Bence-Jones protein ?1g/24 h
• Marrow plasmacytosis of 10–30%
• M-component present
• Lytic bone lesions
• Immunoglobulin levels reduced to less than 50% of normal
1The diagnosis of multiple myeloma requires one major and one minor criteria
or three minor criteria (must include marrow plasmacytosis and a M-component).
Pathologic Studies of Plasma Cell Dyscrasias 27
plasma cells. Atypical forms may include immature plasma cells with promi-
nent nucleoli, pleomorphic plasma cells including multinucleated and polylo-
bated forms, and even anaplastic cells (fig. 3) not easily identified as plasma
cells. Some patients have immature plasma cells with blastic features
Fig. 1. Bone marrow aspirate smear with marked plasmacytosis and some proplasma-
cytic forms (Wright-Giemsa, original magnification ?400).
Fig. 2. Bone marrow core biopsy replaced by myeloma cells with associated
myelofibrosis (hematoxylin and eosin, original magnification ?400).
(plasmablasts). Cytoplasmic immunoglobulin in the plasma cells may result in
Mott, Russell, and flame cell formation. An accompanying proliferation of his-
tiocytes resembling Gaucher cells and crystalline structures may be observed.
The plasma cells may be distributed in the bone marrow in small clusters, but
sheets of plasma cells may also be evident. Early studies demonstrated that
plasmablastic morphology and a diffuse pattern of marrow infiltration are usu-
ally associated with a poor prognosis [2, 3].
The percentage of bone marrow plasma cells is determined from morpho-
logic examination with or without the use of immunohistochemistry. A bone
marrow aspirate differential may underestimate the degree of bone marrow plas-
macytosis, depending on the site of aspiration. Immunoperoxidase stains of the
core biopsy for CD38 and CD138 (fig. 4) allow easy quantitation of the percent-
age of plasma cells. Immunohistochemistry is a good method for estimating
tumor burden, and is particularly helpful in cases with only a mild plasmacytosis.
When greater than 30% of the marrow cellularity is replaced by plasma cells, a
diagnosis of multiple myeloma is expected. Although reactive plasmacytosis can
rarely be associated with plasma cell infiltrates that comprise over 30% of the
marrow cellularity, detection of large aggregates comprised of more than 10
plasma cells, cytologic atypia, and documentation of clonality are morphologic
features that indicate a neoplastic process. Clonality may be confirmed on core
biopsy recuts utilizing immunoperoxidase stains (fig. 5) or in situ hybridization
Fig. 3. Bone marrow core biopsy with anaplastic multiple myeloma (hematoxylin and
eosin, original magnification ?400).
Pathologic Studies of Plasma Cell Dyscrasias29
Fig. 4. CD38 positive myeloma cells comprise greater than 75% of the marrow cellu-
larity on the immunoperoxidase stain (original magnification ?400).
Fig.5. Immunoperoxidase stain demonstrating ? light chain restriction in the myeloma
cells (original magnification ?400).
Fig. 6. In situ hybridization probe demonstrating ? light chain restriction in the
myeloma cells (original magnification ?400).
probes (fig. 6) for ? and ?. Light chain restriction or clonality is often defined as
a ?:? ratio of greater than 5:1 or less than 1:2. In situ hybridization probes are
characteristically easier to read and have less background staining. In rare cases,
the neoplastic plasma cells are negative on in situ hybridization staining but have
documented clonality on immunoperoxidase staining. Rarely, clonality cannot be
assessed by either staining method. In these cases, clonality must be evaluated on
flow cytometric or molecular genetic studies.
The plasma cell neoplasms are typically characterized by the secretion of a
monoclonal immunoglobulin, often referred to as a M-component. A mono-
clonal immunoglobulin is found in the serum and/or urine of approximately
99% of patients. Serum protein electrophoresis (fig. 7) performed on agarose or
cellulose acetate characteristically reveals a peak or restriction band in the ?
region in these patients. The quantity of the monoclonal protein is determined
by densitometry. On immunofixation (fig. 8) or immunoelectrophoresis, the
monoclonal immunoglobulin can be characterized by identification of the
heavy and light chain isotypes. The monoclonal protein is IgG in approximately
50% of cases. Monoclonal IgA accounts for approximately 20% of cases, fol-
lowed by monoclonal light chains in 15% of cases, and IgD in 2% of cases. In rare
patients, two immunoglobulin clones are identified (diclonal gammopathy).
The type of monoclonal protein produced has prognostic significance with light
chain only patients having the worst median survival and IgA patients having a
Pathologic Studies of Plasma Cell Dyscrasias 31
worse median survival than patients with a monoclonal IgG . In approxi-
mately 1% of patients, the neoplastic plasma cells do not secrete immunoglob-
ulin. This may be due to plasma cells that synthesize, but do not secrete
immunoglobulin or plasma cells that do not synthesize immunoglobulin.
Quantitation of immunoglobulin levels, preferably by nephelometry, is useful
for evaluating the amount of monoclonal protein, the levels of residual poly-
clonal immunoglobulins, and monitoring response to treatment. Production of
normal immunoglobulins is usually decreased in multiple myeloma due to dis-
placement of normal cells by neoplastic plasma cells. A greater than 50%
Fig. 7. Serum protein electrophoresis
demonstrating a major restriction band in the
? region. Densitometric scan reveals that this
M-component comprises approximately 27%
of the total protein (Courtesy of Angela
Fig. 8. Immunofixation electrophore-
sis reveals that the monoclonal protein is
IgG ? (Courtesy of Angela Grantham).
reduction in normal serum immunoglobulin levels is often evident, resulting in
recurrent infections. Rarely, immunoglobulin levels are normal. When evaluat-
ing monoclonal proteins in urine, a 24-hour urine collection is essential. The
total amount of protein excreted per day is calculated. An aliquot of the sample
is utilized for protein electrophoresis and immunofixation. The amount of the
monoclonal protein in urine can be estimated from the percentage of mono-
clonal protein in the aliquot and the total 24-hour urine protein.
An immunoassay for serum free light chains allows quantitation of ? and ?
light chains that are in circulation, but are not bound to immunoglobulin heavy
chains. Quantitation of ? and ? free light chains and determination of a ?:? ratio
is a sensitive and specific method for detecting free light chain diseases  such
as primary systemic amyloidosis, light chain deposition disease, non-secretory
multiple myeloma, and light chain multiple myeloma. The combination of serum
protein electrophoresis and immunofixation with the quantitative free light chain
assay improves detection of some patients with plasma cell dyscrasias. The
quantitative free light chain assay is also useful for monitoring treated patients.
Assessment of hematologic parameters in patients with plasma cell
dyscrasias typically includes a complete blood count with differential and
peripheral blood smear examination. Anemia often occurs, a result of marrow
effacement and decreased erythropoietin production by damaged kidneys. The
anemia is usually normocytic and normochromic and often moderate in sever-
ity. Peripheral blood leukocyte counts are usually normal and thrombocytopenia
is uncommon. Increasing numbers of plasma cells in the peripheral blood are
usually associated with advanced stages of disease, and leukemic myelomatosis
(fig. 9) is uncommon. Hypergammaglobulinemia is often associated with
rouleaux (fig. 10) formation on the peripheral blood smear as well as an
increased erythrocyte sedimentation rate. Rarely, excess immunoglobulin pro-
duced results in an increased serum viscosity and hyperviscosity syndrome.
Monoclonal proteins can interfere with the function of coagulation factors and
result in a prolongation of the prothrombin time and activated partial thrombo-
plastin time that may be associated with bleeding complications.
Numerous biochemical laboratory studies are essential for the diagnosis
and staging of patients with plasma cell dyscrasias and the monitoring of their
response to treatment. Monoclonal light chains in the urine (Bence-Jones pro-
tein) cause tubular damage that leads to renal failure. Renal function has a
major impact on prognosis . Approximately 25% of patients have creatinine
levels ?2mg/dl at diagnosis and many more develop renal insufficiency as
their disease progresses. The skeletal destruction that occurs in multiple
myeloma frequently results in hypercalcemia. Hyperuricemia is also noted in
up to one-third of patients. Increased serum lactate dehydrogenase (LDH) level,
a result of cell turnover, is characteristically seen in aggressive forms of the
Pathologic Studies of Plasma Cell Dyscrasias 33
Fig. 9. Peripheral blood smear with secondary plasma cell leukemia or ‘leukemic
myelomatosis’(Wright-Giemsa, original magnification ?400).
Fig. 10. Peripheral blood smear with rouleaux formation (Wright-Giemsa, original
disease. ?2-Microglobulin is an independent prognostic variable in multiple
myeloma. Increased ?2-microglobulin is associated with advanced myeloma
stage and a poor prognosis. Previous studies have shown however that ?2-
microglobulin levels are not helpful for monitoring the course of the disease
. Serum albumin is another important prognostic variable. Low serum albu-
min is associated with rapid disease progression and a poor performance status.
The new International Staging System  and the previously proposed
Southwest Oncology Group stages  indicated that ?2-microglobulin and
serum albumin are the best markers to stratify prognostic subgroups.
Flow cytometric studies are performed on cell suspensions from bone mar-
row aspirates collected in EDTA. These studies may also be performed on unfixed
core biopsies subjected to vortex disaggregation. Fine needle aspiration is useful
for sampling soft tissue lesions. Flow cytometric studies for evaluation of a plasma
cell dyscrasia characteristically include (at a minimum) monoclonal antibodies for
CD45, CD38, CD138, ?, and ?. Plasma cells characteristically express CD38 and
CD138 but do not express CD45. They also express CD19, but do not typically
express other mature B cell markers, including CD20 and CD22. Evaluation of
light chain expression is performed utilizing cytoplasmic ?and ?and selective gat-
ing on CD38 and CD138 positive cells (fig. 11). The majority of neoplastic plasma
cells exhibit light chain restriction on cytoplasmic ? and ? studies (a marker of
clonality) and two or more aberrant immunophenotypic markers . Other com-
mon phenotypic abnormalities include expression of CD56, decreased expression
of CD38, and loss of CD19 expression. Less frequently reported abnormalities
include expression of CD10, expression of CD20, expression of CD22, or expression
[Ungated] FL2 Log/FL4 Log-ADC
(5,000) [A] FL1 Log/FL2 Log-ADC
Fig. 11. Flow cytometry studies reveal that CD38 and CD138 positive plasma cells
comprise 15% of the marrow cellularity. Lambda light chain restriction is evident (Courtesy
of Angela Grantham).
Pathologic Studies of Plasma Cell Dyscrasias35
of CD28. Because of these phenotypic abnormalities, coexistence of residual nor-
mal plasma cells and neoplastic plasma cells, a common finding in patients with
monoclonal gammopathy of undetermined significance (MGUS), can be readily
detected. The prognostic significance of the myeloma cell phenotype has been
evaluated in multiple studies. An immature phenotype with expression of CD20
and surface immunoglobulin, lack of CD56, or overexpression of CD19, CD28, or
CD44 have been associated with a poor prognosis. Adhesion molecules such as
CD56 may have an important role in the development of extramedullary disease
and plasma cell leukemia [11, 12]. Expression of antigens associated with multi-
drug resistance, may be associated with a poor response to traditional therapeutic
agents. While flow cytometric studies are useful in the identification of plasma cell
dyscrasias and monitoring response to treatment , these studies often underes-
timate the percentage of tumor cells and occasionally yield false negative results
(unpublished observations). Negative flow cytometric studies should be followed
by immunohistochemical analysis of core biopsy recuts in cases of suspected dis-
ease. Immunohistochemical evaluation on a core biopsy is the preferred method
for estimating tumor burden . Flow cytometric studies can be utilized to iden-
tify circulating myeloma cells, which may have prognostic significance in some
Flow cytometry is a useful method for the evaluation of DNA content and
plasma cell proliferation. A double staining procedure for plasma cell surface
antigens (such as CD38 and/or CD138) and nuclear DNA (utilizing propidium
iodide) is used for the specific analysis of DNA content and S-phase in marrow
plasma cells. DNA ploidy obtained by flow cytometric studies is expressed as a
DNA index. This index is the ratio of the modal fluorescence channel of the
G0/G1peak of the myeloma cells and the modal fluorescence channel of normal
G0/G1cells present in the sample. A DNA index of 1.0 is considered to be
diploid. If the DNA index is above or below 1.0, the tumor cells are said to be
aneuploid (hypodiploid – DNA index ?0.95 and hyperdiploid – DNA index
?1.05). The reported incidence of DNA aneuploidy varies, but is probably seen
in approximately 50% of cases with multiple myeloma. Most aneuploid tumors
are hyperdiploid and studies indicate that these patients have a better outcome
. Hypodiploid tumors, although less common, have a reportedly worse
prognosis . The percentage of bone marrow plasma cells in S-phase has
been shown to be an independent prognostic factor, with a high number of
plasma cells in S-phase (?2.5%) predicting a poor prognosis . Studies have
indicated that this measure of proliferative activity is the most important prog-
nostic factor in multiple myeloma patients greater than 65 years of age .
Alternatively, proliferative status can be assessed utilizing Ki-67 staining of
plasma cells on sections obtained from the paraffin embedded core biopsy.
Increased Ki-67 expression is associated with advanced disease.
Conventional cytogenetic studies are performed on bone marrow aspirate
collected ideally in sodium heparin. Metaphase cells are analyzed on unstimulated
cell cultures utilizing GTG banding. Conventional cytogenetic analysis is difficult
due to the low proliferative rate of most neoplastic plasma cells, and metaphases
evaluated are often from non-neoplastic bone marrow cells. The utilization of
cytokine stimulated bone marrow cultures and the addition of molecular cytoge-
netic techniques such as fluorescent in situ hybridization (FISH) that eliminate the
need for metaphase cells, have increased the availability and clinical utility of
genetic information. Structural and numerical chromosomal abnormalities are
described in the majority of patients with multiple myeloma, but the prognostic
significance of most of these abnormalities is unknown. Complex karyotypes with
multiple chromosomal gains and losses are most frequently identified. Gains in
chromosomes 3, 5, 7, 9, 11, 15, 19, and 21 are commonly reported. Losses are
often reported in chromosomes 13, 17, X, and Y . Translocations, deletions,
and mutations are also frequently reported. Translocations involving the
immunoglobulin heavy-chain gene (IgH) and various oncogenes are common.
Translocations involving the IgH locus on 14q32 are reported in approximately
half of the patients with multiple myeloma . Monosomy or partial deletion of
chromosome 13 (13q14) is reported in up to 40% of new cases of multiple
myeloma, and is associated with a poor prognosis [18, 19]. Translocations such as
t(11;14)(q13;q32) involving the BCL-1 gene; t(4;14)(p16.3;q32) resulting in acti-
vation of FGFR3 and MMSET genes; t(14;16)(q32;q23) resulting in activation of
c-MAF; and t(14;20)(q32;q11) resulting in MAFB activation are also associated
with a poor prognosis . Deletion of p53, located on the short arm of chromo-
some 17 (17p13.1), is associated with aggressive disease and has been reported
with increased frequency in plasma cell leukemia . Deletion of 7q is associ-
ated with drug resistance and a poor response to therapy. Amplification of chro-
mosome band 1q21, associated with overexpression of the cell cycle regulator
gene CKS1B, is associated with disease progression and a poor prognosis [22,
23]. Trisomies of chromosomes 9 or 19 are associated with a more favorable prog-
nosis. While some abnormalities are detected on conventional cytogenetic studies,
many abnormalities may only be detected by molecular genetic studies utilizing
techniques such as FISH on interphase nuclei. These studies can be performed on
aspirate smears and even paraffin embedded core biopsies. Molecular genetic
studies currently performed on cases of suspected or known plasma cell
dyscrasias vary, but may includes assays for the following: rearrangements of the
(IgH) locus IgH on 14q32; 13q14 deletion; 17p13.1 deletion associated with dele-
tion of p53; t(11;14)(q13;q32) involving the BCL-1 gene; 7q deletion, and assess-
ment of aneuploidy for chromosomes 3, 5, 7, 9, 11, 15, 19, and 21.
FISH studies (fig. 12) have become the preferred method for detecting
non-random cytogenetic changes at the time of diagnosis. Other molecular
Pathologic Studies of Plasma Cell Dyscrasias 37
genetic techniques such as polymerase chain reaction procedures for evaluation
of heavy chain and light chain gene rearrangement can be used to document
clonality. This technique may be helpful in cases where clonality cannot be
demonstrated by other techniques. It can also be useful for documenting resid-
ual clonality when evaluating response to treatment.
Evaluation of the results of these pathologic studies in conjunction with
other clinical and radiologic findings is essential for the diagnosis of multiple
myeloma and other plasma cell dyscrasias. Clinical variants of plasma cell
dyscrasias shown in table 3 are classified based on the quantity of the monoclonal
immunoglobulin, the presence or absence of lytic bone lesions, and the degree of
bone marrow plasmacytosis. Plasma cell leukemia, defined as circulating periph-
eral blood plasma cells greater than 2.0 ? 109/l or 20% of peripheral blood leuko-
cytes, may occur at the time of diagnosis (primary plasma cell leukemia) or may
arise late in the course of the disease (secondary plasma cell leukemia, referred to
also as ‘leukemic myelomatosis’). Plasma cell leukemia is more commonly
observed in light chain only disease or in cases of multiple myeloma that secrete
IgD or IgE. MGUS is considered to be a precursor lesion to multiple myeloma.
These patients have a monoclonal protein but no evidence of multiple myeloma or
other lymphoplasmacytic disorders associated with monoclonal protein produc-
tion. These patients are often asymptomatic and the monoclonal protein is often
incidentally discovered. The disorder is most commonly seen in older individuals
Fig. 12. Fluorescence in-situ hybridization (FISH) demonstrating a translocation involv-
ing the immunoglobulin heavy chain gene (IgH) on chromosome 14 at 14q32. The intact gene
is indicated by a yellow signal and the rearranged gene by an orange and a green signal.
and is reported in approximately 3% of patients over 70 years of age.
Approximately 25% of the patients diagnosed with MGUS have developed multi-
ple myeloma or other lymphoplasmacytic diseases during a 20-year follow-up
. Evolution of the disease typically occurs after approximately 10 years.
Laboratory studies essential for the diagnosis and management of patients
with multiple myeloma and other plasma cell neoplasms are outlined in table 4.
Cytogenetics and molecular genetic studies such as FISH are clinically useful
in the evaluation of prognostic factors that may determine treatment subgroups.
The clinical staging of multiple myeloma is typically based on the level and
type of the M-component, the presence or absence of lytic bone lesions, and the
results of laboratory studies including hemoglobin, serum calcium, and serum
creatinine levels. The Durie-Salmon stage introduced in 1975 is shown in table 5
. This system was the standard staging tool used for many years for patient
stratification and treatment decisions. Creatinine levels provided the basis for
substaging into lower versus higher risk subgroups. Newer staging systems
including the Southwest Oncology Group staging system and the International
Staging System (table 6) are based on the results of a serum ?2-microglobulin
and a serum albumin, two easily obtainable assays .
Table 3. Comparison of MGUS and multiple myeloma variants
IgG ? 3.5g/dl;
IgA ? 2g/dl
IgG ? 3.5g/dl;
IgA ? 2g/dl
IgG ? 3.5–7g/dl;
IgA ? 2–5g/dl
IgG ? 3.5g/dl;
IgA ? 2g/dl
protein in urine
?3 lytic lesions;
Pathologic Studies of Plasma Cell Dyscrasias 39
Table 4. Laboratory studies useful in the evaluation of plasma cell dyscrasias
Laboratory test Clinical significance
Complete blood count Anemia with hemoglobin ?8.5g/dl is
associated with advanced stage of disease
Basic metabolic panelIncreased serum calcium is associated
with advanced stage of disease;
increased creatinine is a result of renal
insufficiency and is associated with a
Serum protein electrophoresisA monoclonal protein or M-component
is found in the serum or urine of the
majority of patients
M-component identification in serum or
urine including Bence-Jones protein in urine
Immunoglobulin levels The amount of M-component is useful
in the diagnosis of multiple myeloma
and its clinical variants; reduced normal
immunoglobulins is a minor criteria
useful in the diagnosis of multiple myeloma
?2-microglobulin Increased ?2-microglobulin is
associated with a poor prognosis
Cytogenetics Complex karyotypes with multiple
chromosomal gains and losses are
most frequently identified
Molecular genetic studies Deletions and gene rearrangements
are common and often associated with
a worse prognosis
Bone marrow aspirate and biopsy Classification of plasma cell dyscrasias
is based on the percentage of plasma
cells in the bone marrow
Immunohistochemistry Stains performed on the core biopsy
are useful for quantitation of plasma
cells; evaluation of plasma cell
proliferation, angiogenesis, and other
prognostic factors can also be performed
Flow cytometry Documentation of clonality and
quantitation of plasma cells may be
performed, ploidy and S-phase have
Laboratory studies used in the evaluation of residual disease following
treatment are similar to those used at the time of diagnosis. Microscopic exam-
ination of a bone marrow aspirate and biopsy for detection of residual disease is
often difficult because of the presence of normal plasma cells. Flow cytometry
and immunohistochemistry are the most useful methods for identification of
residual clonal plasma cells .
New laboratory tests and techniques will continue to be evaluated and inte-
grated into routine testing. Serum levels of interleukin (IL)-6, soluble IL-6
receptor, soluble IL-2 receptor, and expression of IL-2 receptors on bone mar-
row plasma cells or peripheral blood mononuclear cells correlates with disease
activity and disease stage. Serum IL-6 and soluble IL-6 receptor levels are
increased in up to 50% of patients with multiple myeloma, and high levels of
Table 5. Durie-Salmon Staging System
Stage Clinical and laboratory findings
• M-component levels: IgG ?5g/dl,
IgA ?3g/dl, or urine Bence-Jones
• Bone lesions absent or a solitary
• Normal laboratory parameters
including hemoglobin, serum calcium,
and immunoglobulin levels
• M-component levels: IgG ? 5–7g/dl,
IgA ? 3–5g/dl, or urine Bence-
Jones protein 4–12g/24h
• Lytic bone lesions present
• Abnormal laboratory studies
including anemia, increased serum
calcium, and reduced immunoglobulin levels
• M-component levels: IgG ? 7g/dl,
IgA ? 5g/dl, or urine Bence-Jones
• Advanced bone disease with
multiple lytic lesions
• Hemoglobin ?8.5g/dl, serum
Based on renal function
• Serum creatinine ?2mg/dl
• Serum creatinine ?2mg/dl
Pathologic Studies of Plasma Cell Dyscrasias 41
serum IL-6 are associated with a poor prognosis [25, 26]. These studies may
have potential use in cases where other prognostic markers such as ?2-
microglobulin and serum lactate dehydrogenase levels reveal conflicting or bor-
derline results. C-reactive protein, an acute phase reactant, is a reflection of
IL-6 activity. C-reactive protein is increased in approximately 40% of patients
with multiple myeloma. Evaluation of C-reactive protein at diagnosis provides
useful prognostic information. It is an inexpensive and simple assay that can be
used instead of serum IL-6 levels . The evaluation of biochemical markers
of bone disease such as serum ICTP (carboxy-terminal telopeptide of type-I
collage) and urinary Ntx (amino-terminal collagen type-I telopeptide) may lead
to new treatment options .
Immunohistochemical studies for detection of multi-drug resistance, angio-
genesis, or anti-apoptotic factors, although not currently used in routine clinical
practice, will provide important prognostic information for determining treat-
ment protocols in the future [29, 30]. New molecular genetic techniques, such as
target FISH (cell mapping on a stained slide followed by destaining and FISH
analyses of plasma cells)  and clone-specific cytoplasmic immunoglobulin
staining method coupled with FISH (cIg-FISH)  offer new opportunities for
monitoring of residual disease. Gene expression profiles improve our under-
standing of the pathogenesis of these diseases. These molecular insights will
lead to new classification schemes, more targeted therapies, and improved out-
comes in these patients. The continued introduction of new laboratory and other
diagnostic technologies will help to improve our understanding of plasma cell
neoplasms and our approach to the management of these patients.
Table 6. International Staging System (ISS) for multiple
I Serum ?2-microglobulin ?3.5mg/l
Serum albumin ?3.5g/dl
• Serum ?2-microglobulin ?3.5mg/l
but serum albumin ?3.5g/dl
• Serum ?2-microglobulin ?3.5mg/l
but ?5.5mg/l (irrespective of serum
IIISerum ?2-microglobulin ?5.5mg/l
1Stage II has 2 categories.
Technical assistance with images was provided by Angela Grantham, MBA, BS,
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Diana M. Veillon, MD
Department of Pathology, Louisiana State University
Health Sciences Center, 1501 Kings Highway
Shreveport, LA 71103 (USA)
Tel. ?1 318 6755885, Fax ?1 318 6754883, E-Mail firstname.lastname@example.org